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Protective effect of gold rings and rheumatoid arthritis
  1. HORAŢIU D BOLOŞIU
  1. Department of Rheumatology, Medical Clinic II, University of Medicine and Pharmacy “Iuliu Hatieganu” Cluj, Str. Clinicilor 2–4, 3400 Cluj-Napoca, Romania

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    I found the article of Mulherin and colleagues1regarding a presumably protective effect of gold rings against articular erosions in rheumatoid arthritis (RA) very interesting, but it surely raises more problems than it can solve.

    A few years ago we published a similar observation2 that contradicts the hypothesis that the metacarpophalangeal (MCP) joint of the left ring finger would have remained less affected by the disease because of lymphatic drainage of the gold from the ring worn distally to it.

    Our case was a female patient aged 54, suffering from Sjögren’s syndrome with seropositive RA of 25 years duration. Examination of the hands showed typical rheumatoid aspect, with predominant MCP and proximal interphalangeal (PIP) joint involvement in a roughly symmetrical distribution; an augmentation on the dominant hand, the right one, could be seen as well. However, there was an exception from the symmetry of changes: the normal aspect of the fourth left finger (fig 1). These data were confirmed by radiographs showing erosive changes at the MCP and PIP joints of both hands apart from the left ring finger PIP joint, where a mild juxtaarticular osteoporosis was the only change (fig 2). Without another explanation that would have been confirmed by a thorough anamnesis, we had to accept the explanation of the patient, a highly educated person and wife of a physician, that this joint would have been protected by the wedding ring that she was wearing even before the onset of disease. Moreover, a similar effect was noticed by the patient on the fourth finger PIP joint of the opposite hand, on which she had been wearing for a few years an adorning gold ring. That one was removed several years before and the patient noticed that the distal joint began afterwards to deform.

    Figure 1

    The dorsal (A) and palmar (B) aspects of the hand. Note the normal appearance of the fourth finger in the left hand.

    Figure 2

    Radiographic appearance of the hands. The wedding ring was removed as routine by the radiologist.

    The two findings are similar, but differ by the site where the hypothetical protector effect made itself conspicuous, distally and respectively proximally to the position of the gold ring. Our case virtually contradicts the explanation given by Mulherin and colleagues of gold “colonisation” of the MCP joint through local lymphatic drainage and is a challenge to the proposed protective effect, if it exists, of the PIP joint. Without excluding the possibility of a local chemical action, like in the rare cases of local gold toxicity,3 we are inclined to attribute rather a mechanic explanation to the phenomenon.

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